Mindfulness-based cognitive therapy

So other than MBSR, which we considered in the last session, MBCT or mindfulness-based cognitive therapy is probably the most widely recognized and practiced mindfulness intervention. Pioneered in the work of Segal, Williams and Teasdale and now closely associated with the mindfulness research centers in Oxford, Bangor, and Exeter Universities in the UK, MBCT was developed primarily as a treatment protocol to prevent relapse into depression. And it’s been shown to be about twice as effective as medication. Indeed, the evidence base for the effectiveness of MBCT is now so compelling that it’s widely recognized and codified as a treatment by various national health services, medical insurance providers, and clinical watchdogs around the world.

In this session today, we’re going to look at what MBCT is, how it’s used, and whether there are aspects of it that we should be concerned about. Like MBSR from which it draws many major elements, MBCT is also structured around an eight week program, which includes a number of formal meditation practices, the body scan, sitting and walking meditations, mindful movement exercises like stretching or yoga or Qigong. Like MBSR, MBCT causes also make use of periods of inquiry, a form of socratic questioning designed to help participants to reflect on their experiences and to facilitate matter awareness and matter cognition regarding how they react and respond to the experiences they encounter during meditation practices.

We’ll look at this idea of metacognitive standpoints in more detail in the next module. In order to facilitate the generalization of mindfulness skills into everyday life, MBCT also incorporates various informal practices, such as, mindful eating, mindfulness of pleasant and unpleasant experiences, and bringing mindful awareness to various routine activities in which we participate every day, so brushing our teeth, tying our shoelaces and so on. And you’ll be excited to know that we’ll experiment with many of these practices in the meditation labs on this course. With respect to this generalization practices, MBCT places great emphasis on the importance of recognizing our autopilot.

The phrase autopilot is used to label those daily activities that we perform mindlessly, such activities could include things that we’ve gradually conditioned ourselves to do without thinking about them. Often for good reason, ranging from really rudimentary activities like walking through to more complex activities like driving a car. In some of these cases, turning off our autopilot could be disastrous. Learning to drive, for instance, is at least partially a process of programming our autopilot to be able to deal with pedals and gears and controls and steering precisely, so that we don’t have to think about them, and our attention is freed up to watch the road. As soon as we start thinking about them consciously, we have problems driving the car.

However, MBCT also encourages us to become aware of the ways in which we switch into this kind of autopilot on a more ad hoc or reactive basis when were simply distracted by other things or when we are subconsciously seeking to avoid engaging with something. Here we’re not primarily interested in actions of sublimated skill like driving or tying your shoelaces, but we’re trying to identify moments when our minds are not on where we are or what we’re doing, they’re somewhere else instead. The basic insight here is that we spend a surprising amount of our time, everyday, relatively unaware of where we are or what’s going on around us and what we’re really doing.

And really importantly, we’re usually completely unaware that we’re unaware of these things. That is, the focus of our awareness is often not the result of our conscious choice. It is not a reflection of what we really want or where we might want to put our attention. It’s just our autopilot kicking in and living our lives for us, while we’re distracted or averted. It’s literally as though we’re not where we are, as though we’ve been replaced in our daily life by an automaton that just happens to look like us.

For instance, almost all of us, even me and you, will have had the experience of making our way home from work or school or shops, lost in concerns about whether someone had insulted us over lunch. What we’re going to do about food in the evening, or how we’re going to find time to do all that homework before the deadline, and then when we get home, we can’t remember anything at all about the route we took. We didn’t see the dazzlingly beautiful sunset, and we didn’t notice that three friends who tried to talk to us as we failed to notice them on the street. There’s a very real sense in which we were just not present during that walk home.

This kind of experience always reminds me of that wonderful little parable by David Foster Wallace about the meaning of a liberal education. And he said, there are these two young fish swimming along, and they happen to meet an older fish swimming the other way who nods of them and says, morning boys, how’s the water? And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, what the hell’s water?

Of course, the point here is not that autopilot or perhaps daydreaming is necessarily evil or even that it’s always inappropriate or unhealthy, indeed, daydreaming is quite often the highlight of my working day. The point is about cultivating our awareness of where we have placed our attention and cultivating the discipline to place it where we want it to be. Sometimes we’re missing something essential, like water for those fish. Just as we saw in MBSR, awareness, attention, and discipline are core to MBCT. One of the basic insights of MBCT is that our attention is often drawn away from where we are without us being aware of this.

And that particularly for people prone to depression what draws our attention is rumination on problems and regrets and memories of the past or fears and anxieties about the future. So instead of enjoying the water around us or the glorious sunset on our walk home, which really is there in front of us, we spend that walk involuntarily plunged into an internal darkness of our own making. Instead of enjoying a delightful evening walk, they’re thoroughly miserable and stressed the whole time and exhausted when we get home.

This provokes a basic question, would the quality of your life be better if more of it was spent in what you were doing and where you were, less of it were spent entangled in a cycle of worry, anxiety, and stress about things that were not there? If the answer to this question is yes, which probably it is, MBCT aims to provide you with the resources to be more aware of when your autopilot kicks in and with the discipline to make more skillful choices about when you choose to engage it and where you choose to put your attention.

To be clear, it’s not about throwing your autopilot out the window since the autopilot can really valuable and useful which is why planes have autopilots after all. But just about becoming able to register experientially when it turns itself on, being able to make more skillful choices about when your autopilot is nourishing and when it’s depleting. One of the most characteristic practices of MBCT is the brief three minute or three step breathing space, which can be deployed at moments of stress or difficulty during the day, to help center practitioner in the here and now and thus support their ability to make these skillful choices.

If you’re participating in the meditation labs to this course which, of course, you are, you’ll become familiar with this simple technique, and we’ll be doing it a lot. Just as we saw with MBSR in the last session, while studies demonstrate its general effectiveness, the MBCT program does not seem to work for everyone. Again, there are all kinds of possible reason for this, however given the fact that MBCT usually takes place in clinical settings for populations with particular diagnose needs, great emphasis is being placed on trying to understand the responsibilities and role of the instructor as a variable in the effectiveness of the program.

In their seminal work on the establishment of MBCT, Segal, Williams, and Teasdale have outlined the basic requirements for responsible and accredited instructors. You can see the code of practice based on their work that is used today in the supporting documents for this module. And in brief, they argue that at the very least, teachers should be properly qualified in psychotherapy and also that they should have completed a full training program at MBCT, which usually takes about two years. But most importantly, such teachers should also have an established, long-term, ongoing meditation practice of their own.

And it’s this last criteria that’s attracted most interest, since it suggests that the level of mindfulness attained by a teacher makes a real difference to the experiences of her students and to the efficaciousness of mindfulness training itself. For some, this argument might taste a little esoteric, as though it’s a way of smuggling Buddhist mindfulness conventions into a secular construct mindfulness program. However, rather than suggesting that there’s some sort of mystical osmosis involved in the transference of mindfulness from master to disciple, research about MBCT suggest that experienced mediators are better able to embody and model the qualities that the program seeks to promote. And that this modeling is important to the success of treatment.

In particular, mindfulness is often associated with embracing what Mark Williams has called being mode, in preference to a more instrumental doing mode. Being mode is related to a capacity to accept the present moment with a non-striving attitude and to remain in it without judgment. You might notice that this mode seems to resemble the constellation of dispositions that Jon Kabat-Zinn called the Attitudinal Foundations of Mindfulness in our last session on MBSR. On the other hand, doing mode is related to striving for goal-oriented changes to the present moment. Judging the present as different from how it might otherwise have been, and thus flavoring it with disease and dissatisfaction.

As we see in the meditation labs of this course, there are any number of times in an MBCT class at which a teacher might undermine the value of being mode by abruptly, and probably inadvertently, shifting into doing mode in order to fix the problems of a participant. The inquiry process at MBCT should provide space for the embodied compassion and acceptance of the instructor to facilitate the discovery of experiential first person knowledge by the participants. Should not be a directive, didactic or change-oriented exchange in which the instructor tells people how their experiences should feel. Research suggests that it’s very difficult to fake this therapeutic space of compassionate open awareness.

It also shows that it’s very difficult for even experienced therapists, trained in other forms of therapy but relatively inexperienced in mindfulness, to avoid accidentally lapsing into the model of directive and didactic counseling. Indeed, one of the great benefits of an established personal practice for therapists is that they become more aware of and more attuned to those moments when their own autopilot kicks in during classes. There could be few things less appropriate or helpful than an MBCT session with a mindless therapist, who isn’t authentically present. And it’s at least partially for this reason that scientists and other mindfulness practitioners constantly debate the power and role of authenticity and integrity in the person of the teacher or therapist.

It’s a hot topic, and we have no definitive answers. So having now considered the basics of MBSR and MBCT, the next step for us is to take a bit of a step back and to look at mindfulness interventions as a whole to see whether we can identify some common characteristics and features. And this is what we’ll attempt in the next session.